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Background: Rho kinase inhibitors, such as netarsudil, are a relatively new class of medications recently introduced into the market for the treatment of glaucoma, the leading cause of irreversible blindness in the world. Previous clinical trials have studied netarsudil's efficacy when used as a first- or second-line agent but limited studies have investigated its effectiveness in the real world where it is more commonly used as a third, fourth, or fifth agent in combination with other topical medications. Equally important, prior studies have not compared its effectiveness to its peer medications in these settings., Objective: To compare intraocular pressure (IOP) lowering after initiation of netarsudil or brimonidine therapy in patients with glaucoma using >2 medications for IOP management., Methods: A chart review of 369 eyes from 279 patients followed at a single academic tertiary practice was performed with an institutional review board waiver of consent to compare IOP lowering after prescription of netarsudil (n = 176) versus brimonidine (n = 193) as a third, fourth, or fifth IOP-lowering agent. Patients were identified by querying the electronic medical record for those with a glaucoma-related diagnosis who were prescribed either medication. Five sequential IOP measurements were obtained to determine the mean change in IOP before and after treatment (ΔIOP = mean IOP 4,5 - mean IOP 1,2,3 ). A multilevel linear mixed-effects model assessed the influence of medication (independent variable) on ΔIOP (dependent variable). Additional independent variables of interest included the number of glaucoma medications at baseline, age, sex, glaucoma type and severity, race, and pretreatment IOP. Bootstrap analysis was performed to remove sampling bias and confirm mixed-effects model findings. Kaplan-Meier survival analysis evaluated the probability of requiring additional intervention within 3 years following the date of medication prescription., Results: The unadjusted mean (SD) ΔIOP for netarsudil and brimonidine was -2.20 (4.11) mm Hg and -2.21 (3.25) mm Hg, respectively ( P  = 0.484). The adjusted linear mixed-effects models and bootstrap analysis demonstrated that there was no statistical difference in IOP-lowering effectiveness between the medications. Netarsudil and brimonidine failed to adequately control IOP at similar rates with 42% and 47% probabilities of survival respectively by the 3-year follow-up ( P  = 0.520)., Conclusions: When escalating pharmacologic therapy, the IOP-lowering effect of netarsudil appeared to be similar to that produced by brimonidine. ( Curr Ther Res Clin Exp . 2023; 84:XXX-XXX)., Competing Interests: J. Yohannan is a consultant for Abbvie and Ivastis and receives research support from Genentech. The authors have indicated that they have no other conflicts of interest regarding the content of this article., (© 2022 The Author(s).)

Purpose: To compare early postoperative intraocular pressure (IOP) in patients who underwent cataract surgery alone with those who underwent cataract surgery combined with implantation of a Hydrus Microstent (HMS) (Ivantis, Irvine, CA)., Design: Subanalysis of data from the randomized controlled HORIZON trial, a multicenter trial including 26 US and 12 international sites., Participants: Participants with mild/moderate primary open-angle glaucoma (POAG) and visually significant cataract with mean modified diurnal IOP between 22 and 34 mmHg after washout of IOP-lowering medications., Methods: A total of 556 subjects were randomized in a 2:1 ratio to undergo cataract surgery with placement of the HMS versus cataract surgery alone (no microstent [NMS]). All eyes were washed out of IOP-lowering medications before surgery and remained unmedicated until surgery. No IOP-lowering prophylaxis was used postoperatively. Comprehensive eye examination including measurement of intraocular pressure was conducted on postoperative day (POD) 1, week 1, and month 1., Main Outcome Measures: Postoperative IOP >40 mmHg was analyzed as the primary outcome. Incidence of IOP increase >10 mmHg above baseline, unmedicated IOP, and mean IOP were analyzed as secondary outcomes., Results: A total of 369 eyes were randomized to the HMS group, and 187 eyes were randomized to cataract surgery alone. The HMS and NMS groups did not differ with respect to baseline demographic or ocular characteristics. On POD1, the incidence of IOP spike >40 mmHg was significantly higher at 14.4% in the NMS group compared with 1.4% in the HMS group (P < 0.001). The incidence of IOP increase ≥10 mmHg relative to baseline on POD1 was also significantly higher in the NMS group than in the HMS group (22.5% vs. 3.0%, P < 0.001). IOP in the NMS group was significantly higher than in the HMS group (27.6 vs. 17.0 mmHg, P < 0.001). In multivariable logistic regression analysis, higher baseline IOP predicted higher odds of POD1 IOP spike >40 mmHg, whereas the presence of HMS was associated with a lower likelihood of postoperative IOP spike., Conclusions: The addition of an HMS at the time of cataract surgery lowered the risk of markedly elevated IOP in the early postoperative period in patients with glaucoma., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background: Sturge-Weber syndrome is a neurocutaneous disorder associated with epilepsy, glaucoma, cognitive impairments, and a port-wine birthmark. Although individuals with Sturge-Weber syndrome are vulnerable to known risk factors for suicide, including chronic illness and physical differences (port-wine birthmark), frequency of suicidal ideation and attempts, and the clinical factors associated with suicide risk, in patients with Sturge-Weber syndrome is unknown., Methods: As a part of routine hospital practice, all outpatients aged eight years and older underwent suicide risk screening during nursing triage using a standardized suicide screening tool. Suicide risk screening results, demographic variables, and medical history (as available) for patients with Sturge-Weber syndrome (N = 34; median age = 15.5; range = 8 to 47 years, 44% male) and other neurological conditions seen at the same institution (N = 369; median age = 14; range = 8 to 78 years, 66% male) were used for retrospective within- and between-group analysis., Results: In the combined sample of Sturge-Weber syndrome and neurologically involved patients, a positive suicide risk screen was related to Sturge-Weber syndrome diagnosis (P = 0.043); analysis by sex showed increased risk of Sturge-Weber syndrome diagnosis in males (P = 0.008), but not in females. Within the Sturge-Weber syndrome group, use of a selective serotonin reuptake inhibitor (P = 0.019) was related to a positive risk screen., Conclusion: People with Sturge-Weber syndrome may be at greater risk of suicidal thoughts or behaviors than those with other neurological conditions. Further study of suicide risk in patients with Sturge-Weber syndrome is needed., (Copyright © 2020. Published by Elsevier Inc.)

Purpose: To assess the effectiveness of topical ocular hypotensive medications in patients with open-angle glaucoma and to identify factors associated with postwashout intraocular pressure (IOP) elevation., Design: Secondary analysis of prerandomization data from 2 prospective, multicenter, randomized clinical trials., Methods: Fourteen hundred subjects (1,400 eyes, 781 from the HORIZON study of the Hydrus micro-stent and 619 from the COMPASS study of the Cypass micro-stent) with primary open-angle glaucoma who were using 0-4 classes of topical IOP-lowering medication underwent Goldmann applanation tonometry before and after a protocol-defined washout period., Results: The mean (standard deviation) age was 70.7 (8.0) years and 55.6% were female. The change in IOP following washout for patients using 0 (n = 100), 1 (n = 705), 2 (n = 355), 3 (n = 214), or 4 (n = 26) medications was 0.2 (2.8), 5.7 (3.3), 6.9 (3.7), 8.8 (5.0), and 9.5 (4.1) mm Hg, respectively (P < .001, Kruskal-Wallis test). Postwashout IOP change was similar between the HORIZON and COMPASS cohorts. No difference in postwashout IOP change was detected among individual prostaglandin analogues in patients on monotherapy. A generalized linear model identified the following factors to be associated with greater IOP rise upon medication washout: greater number of glaucoma medications, higher unmedicated IOP, thinner central corneal thickness (CCT), lack of prior selective laser trabeculoplasty (SLT), and male sex., Conclusions: Cessation of glaucoma medications results in a dose-dependent IOP increase in treated open-angle glaucoma patients. Two independent clinical trial cohorts exhibit similar levels of IOP elevation upon washout, using standardized methodology to estimate real-world medication effectiveness. Thicker CCT and history of SLT may predict reduced response to IOP lowering medications., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: To compare the efficacy of different microinvasive glaucoma surgery (MIGS) devices for reducing intraocular pressure (IOP) and medications in open-angle glaucoma (OAG)., Design: Prospective, multicenter, randomized clinical trial., Participants: One hundred fifty-two eyes from 152 patients aged 45 to 84 years with OAG, Shaffer angle grade III-IV, best-corrected visual acuity (BCVA) 20/30 or better, and IOP 23 to 39 mmHg after washout of all hypotensive medications. Eyes with secondary glaucoma other than pseudoexfoliative or pigmentary glaucoma, angle closure, previous incisional glaucoma surgery, or any significant ocular pathology other than glaucoma were excluded., Intervention: Study eyes were randomized 1:1 to standalone MIGS consisting of either 1 Hydrus Microstent (Ivantis, Inc, Irvine, CA) or 2 iStent Trabecular Micro Bypass devices (Glaukos Inc, San Clemente, CA). Follow-up was performed 1 day, 1 week, and 1, 3, 6, and 12 months postoperatively., Main Outcome Measures: Within-group and between-group differences in IOP and medications at 12 months and complete surgical success defined as freedom from repeat glaucoma surgery, IOP 18 mmHg or less, and no glaucoma medications. Safety measures included the frequency of surgical complications, changes in visual acuity, slit-lamp findings, and adverse events., Results: Study groups were well matched for baseline demographics, glaucoma status, medication use, and baseline IOP. Twelve-month follow-up was completed in 148 of 152 randomized subjects (97.3%). At 12 months, the Hydrus had a greater rate of complete surgical success (P < 0.001) and reduced medication use (difference = -0.6 medications, P = 0.004). More Hydrus subjects were medication free at 12 months (difference = 22.6% P = 0.0057). Secondary glaucoma surgery was performed in 2 eyes in the 2-iStent group (3.9%) and in none of the Hydrus eyes. Two eyes in the Hydrus group and 1 in the 2-iStent group had BCVA loss of ≥2 lines., Conclusion: Standalone MIGS in OAG with the Hydrus resulted in a higher surgical success rate and fewer medications compared with the 2-iStent procedure. The 2 MIGS devices have similar safety profiles., (Copyright © 2019 American Academy of Ophthalmology. All rights reserved.)

Precis: A modified closure for trabeculectomy in which the conjunctiva is incised posterior to the limbus and reapproximated using 2 nylon sutures, provided similar surgical outcomes to the standard trabeculectomy closure technique., Purpose: To examine the surgical outcomes of a modified trabeculectomy closure technique in which the conjunctiva is incised posterior to the limbus and reapproximated using 2 sutures, burying the posterior conjunctiva under an anterior lip of conjunctiva., Materials and Methods: This retrospective review included 73 eyes that underwent trabeculectomies between 2015 and 2017 at Johns Hopkins Hospital by a single surgeon. We analyzed traditional closures used from January 2015 to May 2016, and modified closures used from July 2016 to March 2017. The main outcome measures were a reduction in intraocular pressure at 3, 6, and 12 months, reduction in the number of medications at 12 months, and total number of postoperative complications., Results: There was no difference in reduction of intraocular pressure at 3 months (9.9±8.2 vs. 10.5±8.7 mm Hg), 6 months (10.8±9.6 vs. 10.6±8.3 mm Hg), or 12 months (12.2±8.9 vs. 10.0±9.3 mm Hg) in the standard (n=44) and modified groups (n=29), respectively. There was a similar reduction in the use of glaucoma medications in the standard group (1.2±1.5 vs. 1.0±1.1) compared with the modified group and no difference in the number of postoperative complications (25.0% vs. 17.2%, respectively) (P>0.05 for all)., Conclusions: The modified closure provided similar results to the standard closure for trabeculectomy. Further studies are needed to determine whether the 2 techniques differ in surgical outcomes over a longer follow-up or other surgical parameters (eg, ease, surgical time, learning curve).

Objective: To compare cataract surgery with implantation of a Schlemm canal microstent with cataract surgery alone for the reduction of intraocular pressure (IOP) and medication use after 24 months., Design: Prospective, multicenter, single-masked, randomized controlled trial., Participants: Subjects with concomitant primary open-angle glaucoma (POAG), visually significant cataract, and washed-out modified diurnal IOP (MDIOP) between 22 and 34 mmHg., Methods: Subjects were randomized 2:1 to receive a single Hydrus Microstent (Ivantis, Inc, Irvine, CA) in the Schlemm canal or no stent after uncomplicated phacoemulsification. Comprehensive eye examinations were conducted 1 day, 1 week, and 1, 3, 6, 12, 18, and 24 months postoperatively. Medication washout and MDIOP measurement were repeated at 12 and 24 months., Main Outcome Measures: The primary and secondary effectiveness end points were the proportion of subjects demonstrating a 20% or greater reduction in unmedicated MDIOP and change in mean MDIOP from baseline at 24 months, respectively. Hypotensive medication use was tracked throughout the course of follow-up. Safety measures included the frequency of surgical complications and adverse events., Results: A total of 369 eyes were randomized after phacoemulsification to Hydrus Microstent (HMS) and 187 to no microstent (NMS). At 24 months, unmedicated MDIOP was reduced by ≥20% in 77.3% of HMS group eyes and in 57.8% of NMS group eyes (difference = 19.5%, 95% confidence interval [CI] 11.2%-27.8%, P < 0.001). The mean reduction in 24-month unmedicated MDIOP was -7.6±4.1 mmHg (mean ± standard deviation) in the HMS group and -5.3±3.9 mmHg in the NMS group (difference = -2.3 mmHg; 95% CI, -3.0 to -1.6; P < 0.001). The mean number of medications was reduced from 1.7±0.9 at baseline to 0.3±0.8 at 24 months in the HMS group and from 1.7±0.9 to 0.7±0.9 in the NMS group (difference = -0.4 medications; P < 0.001). There were no serious ocular adverse events related to the microstent, and no significant differences in safety parameters between the 2 groups., Conclusions: This 24-month multicenter randomized controlled trial demonstrated superior reduction in MDIOP and medication use among subjects with mild-to-moderate POAG who received a Schlemm canal microstent combined with phacoemulsification compared with phacoemulsification alone., (Copyright © 2018 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Importance: Exposure of the tube of an aqueous drainage device (ADD) through the conjunctiva is a serious complication of ADD surgery. Although placement of gamma-irradiated sterile cornea (GISC) as a patch graft over the tube is commonly performed, exposures still occur., Objectives: To measure GISC patch graft thickness as a function of time after surgery, estimate the rate of graft thinning, and determine risk factors for graft thinning., Design, Setting, and Participants: Cross-sectional study of graft thickness using anterior segment optic coherence tomography (AS-OCT) was conducted at the Wilmer Eye Institute at Johns Hopkins Hospital. A total of 107 patients (120 eyes, 120 ADDs) 18 years or older who underwent ADD surgery at Johns Hopkins with GISC patch graft between July 1, 2010, and October 31, 2016, were enrolled., Intervention: Implantation of ADD with placement of GISC patch graft over the tube., Main Outcomes and Measures: Graft thickness vs time after ADD surgery and risk factors for undetectable graft., Results: Of the 107 patients included in the analysis, the mean (SD) age of the cohort was 64 (16.2) years, 49 (45.8%) were male, and 43 (40.2%) were African American. The mean time of measurement after surgery was 1.7 years (range, 1 day to 6 years). Thinner grafts were observed as the time after surgery lengthened (β regression coefficient, -60 µm per year since surgery; 95% CI, -80 µm to -40 µm). The odds ratio of undetectable grafts per year after ADD surgery was 2.1 (95% CI, 1.5-3.0; P < .001). Age, sex, race, type of ADD, quadrant of ADD placement, diagnosis of uveitis or dry eye, and prior conjunctival surgery were not correlated with the presence or absence of the graft., Conclusions and Relevance: Gamma-irradiated sterile corneal patch grafts do not always retain their integrity after ADD surgery. Data from this cross-sectional study showed that on average, the longer the time after surgery, the thinner the graft. These findings suggest that placement of a GISC patch graft is no guarantee against tube exposure, and that better strategies are needed for preventing this complication.

Importance: Suboptimal overlap in outcomes reported in clinical trials and systematic reviews compromises efforts to compare and summarize results across these studies., Objectives: To examine the most frequent outcomes used in trials and reviews of the 4 most prevalent eye diseases (age-related macular degeneration [AMD], cataract, diabetic retinopathy [DR], and glaucoma) and the overlap between outcomes in the reviews and the trials included in the reviews., Design, Setting, and Participants: This cross-sectional study examined all Cochrane reviews that addressed AMD, cataract, DR, and glaucoma; were published as of July 20, 2016; and included at least 1 trial and the trials included in the reviews. For each disease, a pair of clinical experts independently classified all outcomes and resolved discrepancies. Outcomes (outcome domains) were then compared separately for each disease., Main Outcomes and Measures: Proportion of review outcomes also reported in trials and vice versa., Results: This study included 56 reviews that comprised 414 trials. Although the median number of outcomes per trial and per review was the same (n = 5) for each disease, the trials included a greater number of outcomes overall than did the reviews, ranging from 2.9 times greater (89 vs 30 outcomes for glaucoma) to 4.9 times greater (107 vs 22 outcomes for AMD). Most review outcomes, ranging from 14 of 19 outcomes (73.7%) (for DR) to 27 of 29 outcomes (93.1%) (for cataract), were also reported in the trials. For trial outcomes, however, the proportion also named in reviews was low, ranging from 19 of 107 outcomes (17.8%) (for AMD) to 24 of 89 outcomes (27.0%) (for glaucoma). Only 1 outcome (visual acuity) was consistently reported in greater than half the trials and greater than half the reviews., Conclusions and Relevance: Although most review outcomes were reported in the trials, most trial outcomes were not reported in the reviews. The current analysis focused on outcome domains, which might underestimate the problem of inconsistent outcomes. Other important elements of an outcome (ie, specific measurement, specific metric, method of aggregation, and time points) might have differed even though the domains overlapped. Inconsistency in trial outcomes may impede research synthesis and indicates the need for disease-specific core outcome sets in ophthalmology.

PurposeThe purpose of the study was to evaluate the safety and efficacy of gamma-irradiated sterile cornea (GISC) for covering the tube in aqueous drainage device (ADD) surgery in a retrospective, multicenter case series.Patients and methodsParticipants included 297 patients (321 procedures) who had undergone ADD surgery for the first time using GISC patch at three clinic centers in the United States between April 2009 and July 2012. The medical records of those consecutive patients were reviewed. Preoperative, intraoperative, and postoperative parameters about GISC were collected and analyzed. The main outcome measures were patch graft failure (PGF) and postoperative complications related to GISC.ResultsThree hundred and nineteen eyes in 295 patients were included in the current analysis. Ten out of the 319 eyes experienced PGF with a mean follow-up of 15.4±9.8 (SD) months. The overall cumulative PGF proportion from Kaplan-Meier analysis was 2.6% (95% CI: 0.6-4.7%) at 18 months. We detected two cases of presumed endophthalmitis related to PGF.ConclusionsGISC appears to have a reasonable success rate for preventing tube exposure related to PGF over an 18-month period. This success rate, in combination with other features of GISC (transparency and storage at room temperature), makes it a viable choice for patch graft material during ADD.

We report a case of a suspected Sturge-Weber syndrome variant diagnosed at the age of 58 with the help of enhanced depth imaging spectral-domain ocular coherence tomography (EDI-SDOCT). A 58-year-old female with unilateral glaucoma was suspected to have choroidal vascular lesion, conjunctival angioma, and no facial port-wine stain who presented to the clinic with bleb dysesthesia many years after trabeculectomy. EDI-SDOCT was performed and revealed markedly increased choroidal thickness in the affected eye. EDI-SDOCT may be helpful in diagnosing Sturge-Weber variants without facial involvement and may aid in the investigation of the pathogenesis of this disease.

Background: Discrepancies between information in conference abstracts and full publications describing the same randomized controlled trial have been reported. The association between author conflicts of interest and the publication of randomized controlled trials is unclear. The objective of this study was to use randomized controlled trials in ophthalmology to evaluate (1) the agreement in the reported main outcome results by comparing abstracts and corresponding publications and (2) the association between the author conflicts of interest and publication of the results presented in the abstracts., Methods: We considered abstracts describing results of randomized controlled trials presented at the 2001-2004 Association for Research in Vision and Ophthalmology conferences as eligible for our study. Through electronic searching and by emailing abstract authors, we identified the earliest publication (journal article) containing results of each abstract's main outcome through November 2013. We categorized the discordance between the main outcome results in the abstract and its paired publication as qualitative (a difference in the direction of the estimated effect) or as quantitative. We used the Association for Research in Vision and Ophthalmology categories for conflicts of interest: financial interest, employee of business with interest, consultant to business with interest, inventor/developer with patent, and receiving ≥ 1 gift from industry in the past year. We calculated the relative risks (RRs) of publication associated with the categories of conflicts of interest for abstracts with results that were statistically significant, not statistically significant, or not reported., Results: We included 513 abstracts, 230 (44.8 %) of which reached publication. Among the 86 pairs with the same main outcome domain at the same time point, 47 pairs (54.7 %) had discordant results: qualitative discordance in 7 pairs and quantitative discordance in 40 pairs. Quantitative discordance was indicated as < 10, 10-20, > 20 %, and unclear in 14, 5, 14, and 7 pairs, respectively. First authors reporting of one or more conflicts of interest was associated with a greater likelihood of publication (RR = 1.31; 95 % CI = 1.04 to 1.64) and a shorter time-to-publication (log-rank p = 0.026). First author conflicts of interests that were associated with publication were financial support (RR = 1.50; 95 % CI = 1.19 to 1.90) and one or more gifts (RR = 1.42; 95 % CI = 1.05 to 1.92). The association between conflicts of interest and publication remained, irrespective of the statistical significance of the results., Conclusions: More than half the abstract/publication pairs exhibited some amount of discordance in the main outcome results, calling into question the dependability of conference abstracts. Regardless of the main outcome results, the conflicts of interests of the abstract's first author were associated with publication.

Importance: Little is known about the necessity of multiple same-day intraocular pressure (IOP) measurements in describing the effect of IOP-lowering surgical procedures, and such evidence could affect surgical trial recruitment and retention of participants., Objective: To determine whether a single IOP measurement might adequately approximate the mean of several measurements in glaucoma surgical trials., Design, Setting, and Participants: A prospective, multicenter, interventional cohort from the prerandomization phase of a randomized clinical trial evaluating use of a supraciliary implant for treatment of IOP was conducted at multiple ophthalmology clinics. A total of 609 patients (609 eyes) with primary open-angle glaucoma and cataract were included., Interventions: One IOP measurement was made while patients were receiving their usual medications to lower IOP, and 3 IOP measurements were made at 8 am, 12 pm, and 4 pm after patients underwent washout of all IOP-lowering eyedrops., Main Outcomes and Measures: The proportion of eyes in which the increase in IOP after washout, using the mean of the 3 measurements, differed by more than 0.5, 1.0, 1.5, or 2.0 mm Hg from the increase in IOP after washout using only 1 of the postwashout measurements. A proportion of 10% or less at the 1.5-mm Hg cutoff was considered clinically acceptable. The hypothesis was formulated after data collection but before the data were examined., Results: The mean (SD) IOP before washout was 18.5 (4.0) mm Hg. The mean increase in IOP after washout, using the mean of the 3 measurements, was 5.3 (4.2) mm Hg. The percentage of eyes in which the increase in IOP using a single postwashout IOP differed from the increase in IOP using the mean of 3 measurements by more than 1.5 mm Hg was 35.1%, 25.6%, 34.2%, 30.0%, and 31.4% when the single measurement was made at 8 am, 12 pm, 4 pm, a randomly chosen single measure of those 3 times, and the time closest to that of the prewashout IOP, respectively. By logistic regression, the 12 pm postwashout IOP had the lowest proportion of eyes differing from the mean (P < .001) and thus most closely approximated the mean diurnal IOP., Conclusions and Relevance: Although eliminating multiple IOP measurements would simplify the conduct of surgical trials in glaucoma, our data show that using a single IOP measurement after washout does not adequately approximate the mean of multiple IOP measurements.

Importance: Laser trabeculoplasty (LTP) is routinely used to treat open-angle glaucoma; hence, understanding variations in its use over time and region is important., Objective: To determine trends over time and the regional variation in the performance of LTP., Design, Setting, and Participants: Database analysis of a 5% random sample of all Medicare beneficiaries 65 years or older with continuous Part B (medical insurance) coverage and no enrollment in a health maintenance organization for each year from 2002 through 2009., Interventions: We counted unique claims with a Current Procedural Terminology code of 65855 (LTP) submitted by ophthalmologists, optometrists, ambulatory surgery centers, or outpatient hospitals by region for each year. We examined trends over time and regional variation in LTP rates in 9 large geographic regions., Main Outcomes and Measures: Rate of LTP per 10,000 Medicare beneficiary person-years and per 10,000 diagnosed open-angle glaucoma (OAG) person-years., Results: The LTP rates per 10,000 Medicare beneficiary person-years were 36.3, 60.1, and 53.5 for 2002, 2006, and 2009, respectively. The 65.6% increase between 2002 and 2006 and the 11.0% decrease between 2006 and 2009 were statistically significant (tests for linear trend, P = .009 and P < .001, respectively). Similarly, the LTP rate among Medicare beneficiaries with OAG increased from 507.9 per 10,000 person-years in 2002 to 824.3 per 10,000 person-years in 2006 (62.3% increase; P = .009) and then decreased to 741 per 10,000 person-years by 2009 (10.1% decrease; P = .004). The rates per 10,000 OAG person-years differed significantly by region, ranging from 314 in the East South-Central region to 607 in the East North-Central region in 2002 (93.2% higher; P < .001). A similar range of variation was observed in subsequent years., Conclusions and Relevance: The rate of LTP for Medicare patients with OAG peaked in 2006 and then decreased through 2009. Nearly twice as many LTP procedures per Medicare beneficiary were performed in some regions compared with others throughout the period.

IMPORTANCE While medication efficacy is well documented in clinical trials, less is known of medication effectiveness in real-world clinical settings. OBJECTIVE To assess the effectiveness of intraocular pressure (IOP)-lowering medications in patients with open-angle glaucoma. DESIGN, SETTING, AND PARTICIPANTS Prospective, multicenter, interventional cohort from the prerandomization phase of a randomized clinical trial at multiple ophthalmology clinics. A total of 603 patients (603 eyes) with primary open-angle glaucoma who were using up to 3 glaucoma medications were included. INTERVENTIONS One IOP measurement was made while the patient was using his or her usual medications to lower IOP (ON IOP). Eligible participants underwent washout of all IOP-lowering drops, and the diurnal IOP was measured 2 to 4 weeks later (OFF IOP). MAIN OUTCOMES AND MEASURES Difference between OFF IOP and ON IOP. The hypothesis was formulated after data collection. RESULTS The mean (SD) ON IOPs for participants using 0 (n = 102), 1 (n = 272), 2 (n = 147), or 3 (n = 82) medications were 24.2 (3.2), 17.5 (3.2), 17.2 (3.1), and 17.2 (3.1) mm Hg, respectively. Patients not using medication had a mean (SD) IOP decrease of 0.2 (2.8) mm Hg at the OFF visit. Patients using 1, 2, and 3 medications had mean (SD) IOP increases of 5.4 (3.0), 6.9 (3.3), and 9.0 (3.8) mm Hg, respectively, at the OFF visit. The percentages of patients with less than a 25% increase in IOP were 38%, 21%, and 13% for those using 1, 2, and 3 medications, respectively. CONCLUSIONS AND RELEVANCE Discontinuation of 1, 2, and 3 medications was associated with a clinically significant increase in IOP, although with smaller effects for the second and third medications compared with the first medication. A substantial proportion of patients showed only small changes in IOP after medication washout, suggesting either that they were not using the medication effectively or that the medication itself, although used properly, was not lowering the IOP. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01085357.

Purpose: To determine the risk factors for low intraocular pressure (IOP) and its detrimental consequences after trabeculectomy., Patients and Methods: We performed a retrospective chart review of consecutive patients aged 12 years and above undergoing trabeculectomy alone by 1 of 2 surgeons between May 2000 and October 2008 at the Wilmer Institute., Results: Among 753 eyes of 596 patients, 112 eyes (14.9%) of 103 patients had an IOP of ≤5 mm Hg at ≥3 months postoperatively (late low IOP). Physical signs related to low IOP occurred in 61 eyes of 58 patients, and 40 eyes of 37 patients had revision surgery for low IOP. Physical signs of low IOP included 34 eyes with choroidal detachment or shallow anterior chamber, 10 with hypotony maculopathy, and 7 with both. Compared with 187 control eyes of 165 patients, risk factors for late low IOP included: surgeon 2 (P=0.0003), left eyes (P=0.03), and secondary glaucoma (P=0.05). Physical signs of low IOP were more common in phakic eyes (P=0.03), whereas need for revision surgery was associated with younger age (P=0.01). The presence of hypotony maculopathy significantly decreased the risk of choroidal detachment/shallow anterior chamber (P=0.003). Hypotony maculopathy was associated with younger age (P=0.02)., Conclusions: Late low IOP was more common with techniques used by 1 of 2 surgeons and in eyes with secondary glaucoma. Clinical signs of low IOP were more common in phakic eyes. Younger age was a risk factor for hypotony maculopathy. Hypotony maculopathy and choroidal detachment tend to occur in different eyes.

Purpose: To estimate payments for glaucoma care among Medicare beneficiaries from 2002 to 2009., Design: Database study., Participants: Data from a 5% random sample of Medicare billing information from 2002 to 2009., Methods: Medicare beneficiaries, aged 65 years or older, with both Parts A and B fee-for-service (FFS) enrollment comprised the annual denominator. For each year, we included those with a defined glaucoma diagnostic code linked to a glaucoma visit, diagnostic test, or laser/surgical procedure. Open-angle, angle-closure, and other glaucoma were categorized separately. Claims were classified into glaucoma care, other eye care, and other medical care., Main Outcome Measures: Cost of glaucoma care in the Medicare Fee-for-Service Population., Results: In 2009, total glaucoma payments by Medicare were $37.4 million for this subset, for an overall estimated cost of $748 million, or 0.4% of an estimated cost of $192 billion for all Medicare FFS payments. Office visits comprised approximately one half, diagnostic testing was approximately one-third, and surgical and laser procedures were approximately 10% of glaucoma-related costs. Coded open-angle glaucoma (OAG) and OAG suspects accounted for 87.5% of glaucoma costs, whereas cost per person was highest in "other glaucoma." In 2009, <3% of patients with OAG underwent incisional surgery and approximately 5% had laser trabeculoplasty. Laser iridotomy was the highest cost category among patients with angle-closure glaucoma, whereas office visits was the highest cost category among the "other glaucoma" group. The total cost of nonglaucoma eye care for patients with glaucoma was 67% higher than their glaucoma care costs; these were chiefly costs for cataract surgery and treatment of retinal diseases. From 2002 to 2009, FFS glaucoma care costs calculated in 2009 dollars were stable and cost per person per year in 2009 dollars decreased from $242 to $228 (P = 0.01 by test for linear trend)., Conclusions: Annual glaucoma care costs per person decreased in constant dollars from 2002 to 2009. Cataract and retinal eye care for patients with glaucoma substantially exceeded the cost of their glaucoma care each year. Visit payments represented the largest category of costs., (Copyright © 2013 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the published literature pertaining to the association between anterior segment imaging and gonioscopy and to determine whether such imaging aids in the diagnosis of primary angle closure (PAC)., Methods: Literature searches of the PubMed and Cochrane Library databases were last conducted on July 6, 2011. The searches yielded 371 unique citations. Members of the Ophthalmic Technology Assessment Committee Glaucoma Panel reviewed the titles and abstracts of these articles and selected 134 of possible clinical significance for further review. The panel reviewed the full text of these articles and identified 79 studies meeting the inclusion criteria, for which the panel methodologist assigned a level of evidence based on a standardized grading scheme adopted by the American Academy of Ophthalmology. Three, 70, and 6 studies were rated as providing level I, II, and III evidence, respectively., Results: Quantitative and qualitative parameters defined from ultrasound biomicroscopy (UBM), anterior segment optical coherence tomography (OCT), Scheimpflug photography, and the scanning peripheral anterior chamber depth analyzer (SPAC) demonstrate a strong association with the results of gonioscopy. There is substantial variability in the type of information obtained from each imaging method. Imaging of structures posterior to the iris is possible only with UBM. Direct imaging of the anterior chamber angle (ACA) is possible using UBM and OCT. The ability to acquire OCT images in a completely dark environment allows greater sensitivity in detecting eyes with appositional angle closure. Noncontact imaging using OCT, Scheimpflug photography, or SPAC makes these methods more attractive for large-scale PAC screening than contact imaging using UBM., Conclusions: Although there is evidence suggesting that anterior segment imaging provides useful information in the evaluation of PAC, none of these imaging methods provides sufficient information about the ACA anatomy to be considered a substitute for gonioscopy. Longitudinal studies are needed to validate the diagnostic significance of the parameters measured by these instruments for prospectively identifying individuals at risk for PAC., Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references., (Copyright © 2013 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Importance: With the recent development of enhanced depth imaging spectral-domain optical coherence tomography (SD-OCT), it is now possible to measure choroidal thickness in patients with Sturge-Weber syndrome and detect abnormalities that are not visible as part of the fundus examination., Observations: We were successful in imaging at least 1 eye in 12 individuals with Sturge-Weber syndrome using enhanced depth imaging SD-OCT. Eyes were defined as affected if they manifested at least one of the following: darkened choroid, glaucomatous optic nerve damage, or conjunctival hyperemia. None of the participants had a clinically visible choroidal hemangioma. The affected eyes had over twice the choroidal thickness of the unaffected eyes (mean [SD], 697 [337] μm vs 331 [94] μm; P = .004, determined by use of an unpaired t test). For the 6 unilaterally affected participants who had both eyes imaged, the choroidal thickness was greater in the affected eyes than in the unaffected eyes of 5 participants (mean [SD], 672 [311] μm vs 329 [88] μm; P = .01, determined by use of a paired t test)., Conclusions and Relevance: The advent of enhanced depth imaging SD-OCT has allowed us to quantify choroidal thickness in the posterior pole, even in eyes with a markedly thickened choroid, such as those found in individuals with Sturge-Weber syndrome. Spectral-domain OCT has a much higher resolution (5-10 μm) than B-scan ultrasonography (150 μm) and can be used to distinguish between the retina and the choroid. Furthermore, enhanced depth imaging SD-OCT can detect choroidal thickness in eyes without clinically apparent choroidal abnormalities.

Background: Glaucoma is an acquired degeneration of the optic nerve and a leading cause of blindness worldwide. Medical and surgical treatments that decrease intraocular pressure may prevent visual impairment and blindness., Purpose: To compare the effectiveness of medical, laser, and surgical treatments in adults with open-angle glaucoma with regard to decreasing intraocular pressure and preventing optic nerve damage, vision loss, and visual impairment., Data Sources: MEDLINE, CENTRAL, and an existing database for systematic reviews (through 2 March 2011); MEDLINE, EMBASE, LILACS, and CENTRAL for primary studies (through 30 July 2012)., Study Selection: English-language systematic reviews; randomized, controlled trials; and quasi-randomized, controlled trials for most outcomes and observational studies for quality of life and harms., Data Extraction: Two investigators abstracted or checked information about study design, participants, and outcomes and assessed risk of bias and strength of evidence., Data Synthesis: High-level evidence suggests that medical, laser, and surgical treatments decrease intraocular pressure and that medical treatment and trabeculectomy reduce the risk for optic nerve damage and visual field loss compared with no treatment. The direct effect of treatments on visual impairment and the comparative efficacy of different treatments are not clear. Harms of medical treatment are primarily local (ocular redness, irritation); surgical treatment carries a small risk for more serious complications., Limitation: Heterogeneous outcome definitions and measurements among the included studies; exclusion of many treatment studies that did not stratify results by glaucoma type., Conclusion: Medical and surgical treatments for open-angle glaucoma lower intraocular pressure and reduce the risk for optic nerve damage over the short to medium term. Which treatments best prevent visual disability and improve patient-reported outcomes is unclear.

Purpose: To determine the prevalence of diagnosed glaucoma in the Medicare population and to assess regional variations and trends., Design: Retrospective, cross-sectional study., Participants: A 5% random sample of Medicare beneficiaries aged ≥ 65 years, excluding those in health maintenance organizations., Methods: All claims with a glaucoma diagnosis code submitted by ophthalmologists, optometrists, or ambulatory surgery centers were used to estimate prevalence of the diagnosis of glaucoma for each year from 2002 to 2008. Regional variation in diagnosed glaucoma was examined in 9 large geographic regions and in 179 smaller subregions, controlling for patient characteristics and provider supply., Main Outcome Measures: The prevalence of diagnosed open-angle glaucoma suspect (OAG-s), open-angle glaucoma (OAG), angle-closure glaucoma suspect (ACG-s), and angle-closure glaucoma (ACG), trends over time, and regional variations in prevalence., Results: The overall prevalence increased from 10.4% in 2002 to 11.9% by 2008, largely owing to increase in diagnosed OAG-s (from 3.2% to 4.5%; P<0.001). The relative prevalence of diagnosed OAG compared with diagnosed ACG was 32:1. In 2008, multivariable models showed that the New England and Mid-Atlantic regions had 1.7 times more diagnosed OAG-s than the reference region (East South Central; New England: odds ratio [OR], 1.66; 95% confidence interval [CI], 1.58-1.75; Mid-Atlantic: OR, 1.66; 95% CI, 1.59-1.73). The odds of diagnosed OAG was 36% higher in New England (OR, 1.36; 95% CI, 1.30-1.42) and 31% higher in the Mid-Atlantic (OR, 1.31; 95% CI, 1.26-1.36) than in the reference region. The New England and Mid-Atlantic regions had the highest odds of diagnosed ACG-s and the Mid-Atlantic region had the highest odds of diagnosed ACG. Among 179 subregions, the New York area had high diagnosis rates of all glaucoma types., Conclusions: The relative prevalence of diagnosed ACG compared with diagnosed OAG was lower than expected from population-based data, possibly owing to failure to perform gonioscopy. Substantial regional differences in diagnosed rates existed for all types of glaucoma, even after adjusting for patient characteristics and provider concentration, suggesting possible overdiagnosis in some areas and/or underdiagnosis in other areas. Regionally higher diagnosis rates in the New York area deserve further study., (Copyright © 2012 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine rates of success and complications of trabeculectomy surgery., Design: Case series., Participants: Consecutive patients undergoing trabeculectomy by 2 surgeons between May 2000 and October 2008., Intervention: By using the Wilmer Institute's billing database, we identified all patients at least 12 years of age coded as having undergone trabeculectomy between May 2000 and October 2008 by 1 of 2 glaucoma surgeons and whose surgery was not combined with another operation. From the chart, we abstracted demographic information on the patients and clinical characteristics of the eyes. The Kaplan-Meier product-limit method and Cox proportional hazard models were used to look at success rates and characteristics associated with inadequate intraocular pressure (IOP) reduction. Complications were tabulated., Main Outcome Measures: (1) Success rate of trabeculectomy, as determined by the achievement of each of 4 different IOP goals, with or without IOP-lowering medications; and (2) incidence of surgical complications., Results: During the study period, 797 eyes of 634 persons underwent trabeculectomy without concurrent surgery. The success rates 4 years after surgery, with or without the use of IOP-lowering eye drops, were 70%, 72%, 60%, and 44%, for achievement of target IOP, ≤18 mmHg and ≥20% IOP reduction, ≤15 mmHg and ≥25% reduction, and ≤12 mmHg and ≥30% reduction, respectively. Increased chance of success was associated with European-derived race; use of mitomycin C (MMC); higher concentrations of MMC, when used; and higher preoperative IOP. Age and previous intraocular surgery were not associated with surgical success. Complications included worsening lens opacity in 242 of 443 phakic eyes (55%), loss of ≥3 lines of acuity (Snellen) in 161 eyes (21%), surgery for bleb-related problems in 70 eyes (8.8%), and infection occurring >6 weeks after surgery in 27 eyes (3.4%). A total of 101 eyes of 94 patients had at least 1 subsequent operation for inadequate IOP control., Conclusions: Trabeculectomy surgery performed by 2 experienced glaucoma specialists achieved target IOP at 4 years in 70% of those operated and was associated with progressive cataract and small risks of bleb-related complications. These results are comparable to those reported in smaller series., (Copyright © 2012 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare the success and complications of trabeculectomy performed with limbus-based and fornix-based conjunctival approaches., Design: Retrospective case series with some prospective data collection., Participants: Consecutive patients undergoing trabeculectomy by 2 surgeons between May 2000 and October 2008., Intervention: We performed limbus-based operations during the first 4 years and fornix-based operations during the last 4 years. We collected data by chart review and by examination at the most recent visit. For each follow-up visit, we defined success as undergoing no further glaucoma procedure and achieving one of our intraocular pressure (IOP) criteria. We used Kaplan-Meier survival analysis, Cox proportional hazards models, and generalized estimating equation (GEE) analysis. During 2009, 439 trabeculectomy sites of 347 patients were quantitatively assessed by the Indiana bleb grading system., Main Outcome Measures: (1) Success rate of trabeculectomy, as determined by the achievement of each of our different IOP goals, with or without IOP-lowering medications; and (2) incidence of surgical complications., Results: During the 4 years after surgery, the success rates of limbus-based and fornix-based trabeculectomy were not statistically different for any of our IOP criteria. Blebs after limbus-based surgery were more likely to be graded as higher and to be avascular (GEE model, both P < 0.0001). Four percent of eyes experienced late-onset bleb leaks within 4 years after both limbus- and fornix-based operations; however, limbus-based cases developed bleb leaks significantly later than did fornix-based cases (2.1 vs. 1.0 years; P=0.002, GEE model). Late bleb-associated infection during the first 4 years after surgery occurred more often in limbus-based operations, although statistical significance was borderline (P=0.054, Cox model). Symptomatic hypotony during all available follow-up was more common with fornix-based operations (P=0.01, GEE model). Eyes undergoing the fornix-based operation had a greater risk of cataract surgery in the 4-year period after surgery (P=0.02, Cox model), and fornix-based cases requiring cataract surgery had the operation earlier than limbus-based cases (P=0.002, GEE model)., Conclusions: Success rates are similar between limbus-based and fornix-based trabeculectomy. Limbus-based procedures produce higher, more avascular blebs, with a greater risk of infection. Fornix-based procedures have more symptomatic hypotony and more and earlier cataract development., (Copyright © 2012 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background/aims: To determine if eyelid closure (ELC) after topical prostaglandin instillation provides greater intraocular pressure (IOP) reduction than prostaglandin instillation without ELC., Methods: Patients receiving chronic bilateral prostaglandin monotherapy were enrolled in this study. The study intervention, ELC, was randomly assigned to one eye, while the fellow eye served as control. ELC was performed for either 1 min or 3 min. After a 1-day washout, the IOP was measured in a masked fashion at baseline, 1 h and 24 h, and at a final visit that took place 7-14 days after enrolment. All visits were scheduled during the morning, and every individual patient's visits occurred at similar times during the day. The main outcome was difference between intervention eye and control eye in IOP-lowering from baseline., Results: 51 patients meeting eligibility criteria were enrolled: 25 were randomised to ELC for 1 min and 26 to ELC for 3 min in the intervention eye. The pooled IOP-lowering difference (95% CI, p value) in intervention versus control eyes was 0.24 mm Hg (-0.5 to 0.9, p=0.50), 0.24 mm Hg (-0.7 to 1.2, p=0.61) and 0.24 mm Hg (-0.7 to 1.2, p=0.61) in the overall group, 1 min ELC subgroup and 3 min ELC subgroup, respectively. The effect of ELC did not change significantly across visits., Conclusions: ELC did not provide significant additional IOP reduction compared with no ELC in patients using chronic prostaglandin monotherapy. Trial Registration http://clinicaltrials.gov/ct2/show/NCT0083283.

Objectives/hypothesis: Disease recurrence and adverse wound healing in the form of inflammation, polyposis, adhesions, and middle turbinate lateralization may induce suboptimal outcomes following sinus surgery. The study objective was to assess the safety and effectiveness of a bioabsorbable, steroid-eluting implant used following functional endoscopic sinus surgery in patients with chronic rhinosinusitis (CRS)., Study Design: Prospective, multicenter, single-cohort trial enrolling 50 patients., Methods: The study allowed bilateral or unilateral steroid-eluting implant placement. Oral and topical steroids were withheld for 60 days postoperatively. Endoscopic follow-up was performed to 60 days. Patient-reported outcomes (Sino-Nasal Outcome Test-22 Questionnaire, Rhinosinusitis Disability Index) were collected to 6 months. Efficacy was assessed by grading inflammation, polyp formation, adhesions, and middle turbinate position. Safety assessment included ocular exams at baseline and 30 days., Results: Implants were successfully placed in all 90 sinuses. Mean inflammation scores were minimal at all time points. At 1 month, the prevalence of polypoid edema was 10.0%, significant adhesions 1.1%, and middle turbinate lateralization 4.4%. Changes from baseline in patient-reported outcomes were statistically significant (P < .0001). No clinically significant changes from baseline in intraocular pressure occurred., Conclusions: This consecutive case series provides clinical evidence of the safety, effectiveness, and clinical utility of a bioabsorbable steroid-eluting implant for use in CRS patients. The implant was associated with favorable rates of sinus patency. At 1 month, minimal degrees of inflammation and adhesions were observed, suggesting a positive clinical impact of local steroid delivery without evidence of ocular risk., (Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objective: To provide an evidence-based summary of the outcomes, repeatability, and safety of laser trabeculoplasty for open-angle glaucoma., Methods: A search of the peer-reviewed literature in the PubMed and the Cochrane Library databases was conducted in June 2008 and was last repeated in March 2010 with no date or language restrictions. The search yielded 637 unique citations, of which 145 were considered to be of possible clinical relevance for further review and were included in the evidence analysis., Results: Level I evidence indicates an acceptable long-term efficacy of initial argon laser trabeculoplasty for open-angle glaucoma compared with initial medical treatment. Among the remaining studies, level II evidence supports the efficacy of selective laser trabeculoplasty for lowering intraocular pressure for patients with open-angle glaucoma. Level III evidence supports the efficacy of repeat use of laser trabeculoplasty., Conclusions: Laser trabeculoplasty is successful in lowering intraocular pressure for patients with open-angle glaucoma. At this time, there is no literature establishing the superiority of any particular form of laser trabeculoplasty. The theories of action of laser trabeculoplasty are not elucidated fully. Further research into the differences among the lasers used in trabeculoplasty, the repeatability of the procedure, and techniques of treatment is necessary., Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references., (Copyright © 2011 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To measure choroidal thickness and to determine parameters associated with it., Design: Cross-sectional study., Participants: Seventy-four glaucoma patients and glaucoma suspects., Methods: Spectral domain optical coherence tomography (SD-OCT) scans were obtained to estimate average choroidal thickness in a group of glaucoma suspects and glaucoma patients. The average thickness was calculated from enhanced depth SD-OCT images and manually analyzed with Image J software. Open-angle glaucoma, open-angle glaucoma suspect, primary angle-closure glaucoma, primary angle closure, and primary angle-closure suspect were defined by published criteria. Glaucoma suspects had normal visual fields bilaterally. Glaucoma was defined by specific criteria for optic disc damage and visual field loss in ≥1 eye. The most affected eye was analyzed for comparisons across individuals, and right/left and upper half/lower half comparisons were made to compare thickness against degree of visual field damage., Main Outcome Measures: Average macular and peripapillary choroidal thickness measured using SD-OCT., Results: The choroidal-scleral interface was visualized in 86% and 96% of the macular and peripapillary scans, respectively. In multivariable linear regression analysis, the macular choroid was significantly thinner in association with 4 features: Longer eyes (22 μm per mm longer [95% confidence interval (CI), -33, -11]), older individuals (31 μm thinner per decade older [95% CI, -44, -17]), lower diastolic ocular perfusion pressure (26 μm thinner per 10 mmHg lower [95% CI, 8, 44]), and thicker central corneas (6 μm per 10 μm thicker cornea [95% CI, -10, 0]). The choroid was not significantly thinner in glaucoma patients than in suspects (14 μm [95% CI, -54, 26]; P = 0.5). Peripapillary choroidal thickness was not significantly different between glaucoma and suspect patients. Thickness was not associated with damage severity as estimated by visual field mean deviation or nerve fiber layer thickness, including comparisons of right with left eye or upper with lower values., Conclusions: Age, axial length, CCT, and diastolic ocular perfusion pressure are significantly associated with choroidal thickness in glaucoma suspects and glaucoma patients. Degree of glaucoma damage was not consistently associated with choroidal thickness., Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references., (Copyright © 2011 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Objective: To review the published literature and summarize clinically relevant information about novel, or emerging, surgical techniques for the treatment of open-angle glaucoma and to describe the devices and procedures in proper context of the appropriate patient population, theoretic effects, advantages, and disadvantages., Design: Devices and procedures that have US Food and Drug Administration clearance or are currently in phase III clinical trials in the United States are included: the Fugo blade (Medisurg Ltd., Norristown, PA), Ex-PRESS mini glaucoma shunt (Alcon, Inc., Hunenberg, Switzerland), SOLX Gold Shunt (SOLX Ltd., Boston, MA), excimer laser trabeculotomy (AIDA, Glautec AG, Nurnberg, Germany), canaloplasty (iScience Interventional Corp., Menlo Park, CA), trabeculotomy by internal approach (Trabectome, NeoMedix, Inc., Tustin, CA), and trabecular micro-bypass stent (iStent, Glaukos Corporation, Laguna Hills, CA)., Methods: Literature searches of the PubMed and the Cochrane Library databases were conducted up to October 2009 with no date or language restrictions., Main Outcome Measures: These searches retrieved 192 citations, of which 23 were deemed topically relevant and rated for quality of evidence by the panel methodologist. All studies but one, which was rated as level II evidence, were rated as level III evidence., Results: All of the devices studied showed a statistically significant reduction in intraocular pressure and, in some cases, glaucoma medication use. The success and failure definitions varied among studies, as did the calculated rates. Various types and rates of complications were reported depending on the surgical technique. On the basis of the review of the literature and mechanism of action, the authors also summarized theoretic advantages and disadvantages of each surgery., Conclusions: The novel glaucoma surgeries studied all show some promise as alternative treatments to lower intraocular pressure in the treatment of open-angle glaucoma. It is not possible to conclude whether these novel procedures are superior, equal to, or inferior to surgery such as trabeculectomy or to one another. The studies provide the basis for future comparative or randomized trials of existing glaucoma surgical techniques and other novel procedures., (Copyright © 2011 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Objective: To review the published literature to summarize and evaluate the effectiveness of visual function tests in diagnosing glaucoma and in monitoring progression., Methods: Literature searches of the PubMed and Cochrane Library databases were conducted last on May 7, 2010, and were restricted to citations published on or after January 1, 1994. The search yielded 1063 unique citations. The first author reviewed the titles and abstracts of these articles and selected 185 of possible clinical relevance for further review. The panel members reviewed the full text of these articles and determined that 85 met inclusion criteria. They conducted data abstraction of the 85 studies, and the panel methodologist assigned a level of evidence to each of the selected articles. One study was rated as level I evidence. The remaining articles were classified broadly as providing level II evidence. Studies deemed to provide level III evidence were not included in the assessment., Results: Standard white-on-white automated perimetry remains the most commonly performed test for assessing the visual field, with the Swedish interactive threshold algorithm (SITA) largely replacing full-threshold testing strategies. Frequency-doubling technology and its refinement into Matrix perimetry, as well as short-wavelength automated perimetry, now available with SITA, have been evaluated extensively. Machine learning classifiers seem to be ready for incorporation into software to help distinguish glaucomatous from nonglaucomatous fields. Other technologies, such as multifocal visual-evoked potential and electroretinography, which were designed as objective measures of visual function, provide testing free of patient input, but issues prevent their adoption for glaucoma management., Conclusions: Advances in technology and analytic tools over the past decade have provided us with more rapid and varied ways of assessing visual function in glaucoma, but they have yet to produce definitive guidance on the diagnosis of glaucoma or its progression over time. Further research on an objective measure of visual function is needed., (Copyright © 2011 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)